Author: Zack (Page 1 of 8)

Round 17 (MW) Headache

You are working at Clerkship General when the next chart is put in your rack. It’s a 41-year-old female with a chief complaint of headache.

Initial Vitals:

HR: 56

BP: 172/93

Temp: 98.8F

RR: 18

O2: 97%

Critical Actions:

  1. Check a Blood Glucose
  2. Diagnose Preecclampsia/Ecclampsia
  3. Administer Magnesium
  4. Treat the Hypertension
  5. Discuss with OBGYN and Admit

Pulmonary Embolism (Deep Dive MW R16)

Diagnosing PE:

Step 1: Consciously consider the diagnosis

Step 2: Risk Stratify into low, intermediate, and high risk

Step 3: Choose appropriate testing based on pre-test probability

Classification of PE

  1. High Risk/Massive PE: Hemodynamic Instability
  2. Intermediate Risk/Submassive PE: Right Heart Strain without instability ; or PESI Class 3+
  3. Low Risk/Non-Massive PE: Everything else (no instability, no heart strain, PESI Class 1-2)

Treatment of PE

  1. High Risk/Massive PE: Thrombolytics and often thrombectomy
  2. Intermediate Risk/Submassive PE: Heparin and sometimes intervention
  3. Low Risk/Non-Massive PE: Either discharge with DOAC or admit with heparin

Round 16 (MW) Leg Pain

You are working at Clerkship General when you overhear the base command radio. “Clerkship General. We have a 57 year-old female coming in for leg pain. She just had surgery at your hospital. Her blood pressure is 85/50. We’ll be there in 5 minutes.”

Initial Vitals:

HR: 122

BP: 75/40

Temp: 100.1

RR: 24

O2: 74%

Critical Actions:

  1. Obtain full set of vital signs
  2. Treat the patient’s pain
  3. Diagnose PE without imaging
  4. Stabilize patient prior to imaging
  5. Transfer the patient for thrombectomy

Round 15 (MW) MVA

You are working at Clerkship General when you hear and EMS call on the radio. “Clerkship General, we are activating a trauma alert. We are bringing you a 33 year old male from a high-speed single vehicle collision”

Initial Vitals:

HR: 65

BP: 88/50

Temp: 97.0F

RR: 20

O2: 96% Room Air

Critical Actions:

  1. Apply Cervical Collar
  2. Treat the Patient’s Pain
  3. Give Antibiotics for Open Fracture
  4. Identify and Prioritize Etiologies of Shock in Trauma
  5. Start Vasopressors for Neurogenic Shock

Pediatric Septic Arthritis (Deep Dive R14 MW)

  • Differential
    • Traumatic causes: non-accidental trauma, fracture, dislocation, sprain, strain, tendonitis, osgood schlatter
    • Non-traumatic causes: septic arthritis, transient synovitis, osteomyelitis, SCFE, LCP disease, rheumatologic disease, bony tumors
  • Work-up
    • XRay
    • Labs to evaluate for septic arthritis – CBC BMP ESR CRP
  • Kocher Criteria
    • Non-weight bearing
    • Fever >38.5C
    • ESR >40
    • WBC >12
  • Kocher Criteria Statistics
    • 0 points: 0.2% (or 2% in prospective studies)
    • 1 point: 3% (or 9% in prospective studies)
    • 2 points: 40%
    • 3 points:93%
    • 4 points: 99%
  • Septic Arthritis DX
    • >50,000 WBC
      • Age 0-3mo : group B strep
      • Age 3mo – 12 years: Staph Aureus
      • Age 12-18 years: Gonorrhea
      • Sickle Cell Disease: Salmonella

Round 14 (MW) Leg Pain

You are working a beautiful sunny day in Pennsylvania when the next chart gets put in your rack. It is a 2 year-old male with a leg injury.

Initial Vitals:

HR: 112

BP: 97/67

Temp: 99.2F

RR: 20

O2: 97% Room Air

Critical Actions:

  1. Consider Non-Accidental Trauma
  2. Evaluate for Septic Arthritis
  3. Treat the Childs Pain
  4. Diagnose Lyme Disease
  5. Prescribe Antibiotics (Avoid Doxycycline)

Asthma (Deep Dive R13 MW)

  • Focused Physical Exam
    • Tachypnea and Hypoxemia
    • Able to speak in complete sentences
    • Accessory muscle use/retractions
    • Moving air or quiet on auscultation
  • Basic Treatment Algorithm
    • Albuterol Inhaler
    • Albuterol/Ipratropium Nebulized (Duoneb)
    • Steroids
    • IV Magnesium
    • Non Invasive Ventilation (CPAP or BiPAP)
      • Decreases Work of Breathing
    • Epinepherine
  • Less Common Treatments
    • Benzodiazepines
    • Ketamine
    • Heliox
  • Intubation (Last resort)
    • Use a large ETT (8.0)
    • Increase the Expiratory Time
  • “Permissive Hypercapnea”
    • Appropriate ventilator management of asthma frequently results in mild hypercapnia and respiratory acidosis. IT’S OK
  • Air Trapping
    • Results in decreased preload, obstructive shock and pneumothorax
    • Suspect with high airway pressures and when waveform doesn’t return to zero (see media)
    • Treat by briefly unhooking ventilator and gently pressing on the patient’s chest to get out the trapped air
  • Ventilator Settings
    • Decrease the respiratory rate (ex 10)
    • Increase the tidal volume (although some hypercapnia is permitted)
    • Increase I:E ratio (1:4 or greater)

Round 13 (MW) Respiratory Distress

You are working at Clerkship General when you hear an EMS call: “Clerkship General, we are bringing you a young female in respiratory distress. ETA 2 minutes”

Initial Vitals:

HR: 123

BP: 142/78

Temp: Unknown

RR: 36

O2: 97% (NonRebreather)

Critical Actions:

  1. Give Albuterol, Steroids, and Magnesium
  2. Give either Epinephrine or Terbutaline
  3. Post Intubation Checklist: Sedation, Tubes, and Xray
  4. Choosing Appropriate Vent Settings
  5. Allow permissive hypercapnia

Organophosphate Poisoning (Deep Dive R12 MW)

Introduction

  • Used as pesticides
  • Used as weapons (nerve agents)
    • Sarin Gas, VX Gas, Novichok
  • Transdermal, Inhalation, Ingestion

Clinical Presentation

  • Muscarinic Activation (Dumbels Mnemonic)
    • Defication
    • Urination
    • Myosis
    • Bradycardia, Bronchospasm, and Bronchorrhea
      • “The Killer B’s”
    • Emesis
    • Lacrimation
    • Salivation and Sweating
  • Nicotinic Activation
    • Muscle weakness and paralysis
  • CNS Activation
    • Respiratory Depression
    • Altered Mental Status
    • Seizures

Treatment

  • Atropine
    • Reverses Dumbels
    • Keep giving and doubling the dose until brochorrhea and bradycardia resolve
  • Pralidoxime
    • Only works before ‘aging’ occurs
  • Diazepam
    • Stops the seizures

Round 12 (MW) Respiratory Distress

You are working at Clerkship General when you hear an EMS call on the radio. “Clerkship General. We are bringing you an unresponsive 6-year-old female found foaming at the mouth by her babysitter. ETA 2 minutes.”

Initial Vitals:

BP: 125/80

HR: 62

RR: 34

O2: 81% (Non Rebreather)

Critical Actions:

  1. Grab the Broslow!
  2. Fingerstick Glucose
  3. Choose Endotracheal Tube Size
  4. Administer Atropine until bronchial secretions stop
  5. Pralidoxime

Round 11 (MW) Chest Pain

You are working at Clerkship Rural when the nurse hands you your next chart to see. It’s a 59 year old farmer with chest pain.

Initial Vitals:

BP: 156/97

HR: 110

RR: 22

O2: 98% (Room Air)

Temp: 98.8F

Critical Actions:

  1. Give Aspirin, Nitroglycerin, and Heparin
  2. Identify Posterior STEMI
  3. Assess for Thrombolytic Contraindications and Consent
  4. Transfer for PCI
  5. Diagnose Accelerated Idioventricular Rhythm (AIVR)

Round 10 (MW) Agitation

You are working at Clerkship General when you hear an EMS call on the radio…

“CLERKSHIP GENERAL – We are bringing you an agitated and combative 30 year old male, we’ll see you in 5 minutes.”

Initial Vitals:

BP: 192/105

HR: 134

RR: 22

O2: 99% (Room Air)

Temp: 98.8 F

Critical Actions:

  1. Administer Sedation for Patient/Staff Safety
  2. Intubate the Patient and Obtain Chest Xray
  3. Diagnose Intracranial Hemorrhage
  4. Treat Patients Hypertension
  5. Diagnose Rhabdomyolysis and Give Fluids

Dangerous Actions:

  1. Giving Succinylcholine
  2. Giving B-Blocker (Controversial)

Check Out:

Procrastinators Guide to Emergency Medicine

Round 9 (MW) Altered Mental Status

You are working at Clerkship General when the charge nurse comes and grabs you… “Hey doc, we need you in room 2, this kid looks sick…”

Initial Vitals:

BP: 68/40

HR: 128

RR: 22

O2: 99% (Room Air)

Temp: 103.5F

Critical Actions:

  1. Diagnose Meningitis and Perform Lumbar Puncture
  2. Give Empiric Antibiotics
  3. Treat Septic Shock
  4. Give Steroids
  5. Give Prophylaxis to Close Contacts

Check Out:

Pearson Ravitz Webinar – “Disability Insurance 101 for Residents”

https://us06web.zoom.us/webinar/register/1416806357023/WN_ziYRNc0kT8yAyOOJZ-Xk2g

Round 8 (MW) Groin Pain

You are working at Clerkship General on an overnight shift when the next chart is handed to you. It’s a 35 year old male with a chief complaint of groin pain.

Initial Vitals:

BP: 150/90

HR: 107

RR: 20

O2: 99% (Room Air)

Temp: 98.0F

Critical Actions:

  1. Diagnose Ischemic/Low Flow Priapism
  2. Perform Penile Nerve Block
  3. Aspirate Blood and Irrigate with Saline
  4. Inject Intracavernous Phenylepherine
  5. Diagnose and Treat Ventricular Tachycardia

Flash Pulmonary Edema (aka SCAPE)

  • “Sympathetic Crashing Acute Pulmonary Edema”
  • Pathophysiology – Rapid onset of pulmonary edema caused by sudden hypertension
    • Triggers- Missed Medication, Cocaine, Stress/Anxiety
      • Increase in BP = Increase in afterload
      • Increased afterload causes acute pulmonary edema (in patients with CHF)
      • The worsening pulmonary edema causes shortness of breath which worsens blood pressure and further increases afterload
  • Presentation- Sudden, severe respiratory distress AND hypertension
    • Different than CHF exacerbation
      • Not necessarily caused by hypervolemia
      • More rapid in onset
    • Typically crackles/rales on exam or diffuse B-Lines on POCUS
  • Treatment
    • BiPAP/CPAP
    • High Dose Nitroglycerin
    • Diuretics IF Hypervolemic

Opioid Use Disorder – What You Do Matters!

In this long-form episode we will discuss opioid use disorder, the leading cause of death in young adults in the United States. What you do matters!

  1. Why you should care about OUD
  2. What is OUD
  3. Buprenorphine Works

References

  1. National Safety Counsel Injury Facts
  2. DebunkingDenial – Purdue Pharma and America’s Opioid Epidemic
  3. Addiction Neuroscience 101 – Youtube
  4. Cochran Review – Buprenorphine for OUD

The Rank List

This episode will answer 3 big pre-Match Day questions:

1. How do I go about making my rank list?

2. What about post-interview communication both from and to programs?

3. How does this whole thing called the Match actually work?

Resources:

https://www.emra.org/books/msadvisingguide/preparing-and-submitting-your-rank-list/

Round 14 (Shortness of Breath)

CAUTION: THESE NOTES CONTAIN SPOILERS!!!

Case Introduction

You are sitting at your computer on an otherwise quiet night when a young male is brought into your ED in obvious respiratory distress.

Initial Vitals

  • Temp 98.6
  • HR 99
  • RR 34
  • BP 105/69
  • O2 95%

Critical Actions

  • Give Albuterol + Ipratropium + Steroids
  • Obtain Chest Xray
  • Give Magnesium
  • Place patient on BiPAP
  • Give IV Beta Agonist (Epinephrine)

Final Diagnosis

Status Asthmaticus

Tips and Tricks

Frequently perform verbal reassessments on patients with the examiner (vitals, patient appearance, pain, etc)

Additional Reading

« Older posts

© 2024 EM Clerkship, LLC

Theme by Anders NorenUp ↑